Lately, with the publication of data on almost 17,000 planned American home births, the “home birth debate” has been reignited, sparking all kinds of conversation – some polarizing, some rational, and everything in the middle. A glaring oversight I see in this conversation, though, is that, while statistics are helpful, what’s most important to families making decisions about where to give birth is what is safest for each woman and her baby, in their unique circumstances.
The variability in options and quality of care across the country is stunning. In Southern California, a low-risk woman might have access to several high-quality hospitals, a lovely birth center, and a dozen respected midwives who enjoy good relationships with the local medical community. This woman has the luxury of considering what large data sets may say about the optimal location for her birth.
But this is not reality for too many American women. For them, options may look more like this:
[box] A Kentucky woman has two children at home; one car, which her husband takes to work 6 days a week for 13 hours at a time; and zero wiggle room in the budget. The nearest hospital, which is over 90 minutes away, has a Cesarean rate of over 50% and this woman knows from friends and relatives that admittance there means she loses any say over how she gives birth. While the children’s grandparents are happy to help with childcare when they can, they work full-time, too. For this family, an unnecessary surgery and extended hospital stay or re-hospitalization would be devastating. In Kentucky, 76 out of 120 counties have no obstetricians and many areas where women must drive at least an hour to reach one; there are zero birth centers, and few legal home birth midwives. Because home birth options are so limited by law, there is little transparency about who this family might hire to assist them outside of the hospital. [/box]
[box] In Arizona, a woman is pregnant with her fifth baby. Her first baby was a C-section after a 39-week induction for “suspected big baby,” and she’s regretted agreeing to that non-evidence based induction ever since. Her next three babies were born vaginally with a different, wonderful doctor at that same hospital. After her family moved across the state, she found out the only hospital in her area does not allow vaginal birth for anyone who has ever had a C-section. She’s not willing to have non-medically indicated surgery. Even if she and her husband could afford to travel to another hospital three hours away, they can’t imagine the logistics and expense of taking their four children there to stay for an indefinite amount of time waiting for labor to happen. (Today in Arizona, legislators are debating whether to prohibit women from having supported home birth if they have had a prior C-section or are carrying a breech baby or twins. A seemingly reasonable safety measure? In context, this means a good number of those women will face mandatory surgery at their local hospitals if this bill passes. Some will submit to the surgeries; some will leave the state to give birth; some will have unattended or illegal home births.) [/box]
[box] In Delaware, a woman has experienced a traumatic hospital birth with a doctor who left her feeling sexually abused after forcefully penetrating her several times, although there was no medical emergency. She’s still paying bills from that hospital visit, which ended in PTSD and a failure by the doctor and hospital to respond to her complaints about her mistreatment. She cannot imagine ever entering that facility unless there were a life-threatening emergency. Because of her family’s financial situation and the fact that she has other small children requiring care, it’s not possible for her to travel to another local hospital or to the single birth center in the state. Home birth there is essentially “underground,” with only one legal midwife in the whole state, which translates to a measure of uncertainty about who this woman might hire illegally and how seamless a transfer to the hospital would be, if there is an emergency. [/box]
[box] In Louisiana – the state with the worst infant mortality rate in the U.S. – a woman is pregnant for the fourth time, having had one prior Cesarean, followed by two uncomplicated vaginal births in another state. There is one birth center in Louisiana, but it did not offer vaginal birth after Cesarean as of January 2014, and the only hospital within driving distance has a 47% C-section rate, a ban on vaginal birth after Cesarean, and a local reputation for being unsanitary, poorly staffed, and, based on a Consumer Reports publication, rife with medical safety issues. They don’t allow doulas at all. She applies to the state for permission* to have a well-respected licensed midwife (one of eight in the whole state) attend her at home instead, and is denied because of her previous C-section. [/box]
[box] A woman in New York has her first baby at the local hospital, unmedicated and without intervention. However, she has to fight every step of the way to avoid risky interventions (like this) and must compromise on some things in order to get others. Hospital protocol includes a number of non-evidence-based practices, including routine admission strip, continuous electronic fetal monitoring, restriction to bed on the back, prohibition of anything by mouth except ice chips, and a 12-hour time limit to give birth. Staff is irritated that she has a doula, and upset with her for declining routine procedures. They insist on keeping her healthy baby “in observation” for four hours after he is born despite an Apgar score of 9 and no medical indication. When she begs to meet her new baby, she is told that observation is mandatory. Her husband then attempts to advocate for her and is told CPS could be called if he continues to try to see their baby. Later, the family meets with a lawyer and is told that there is nothing that can be done legally either about the attempt to force certain interventions or to withhold the baby. Both parents realize that entering a hospital again means they have no meaningful right to say “no” to anything. [/box]
[box] In California, a woman who has had a C-section faces a hospital ban of vaginal birth after Cesarean. Her insurance refuses to pay for her to go elsewhere, citing the “lack of medical necessity” of vaginal birth. She spends her entire pregnancy fighting with the insurance company over this policy and is denied six times in her appeals. [/box]
These are the hard choices real women are faced with. We hear from them at ImprovingBirth.org every day. They are not making purely statistical calculations among sterilized ideals of birth locations. They are making difficult, individual analyses among limited options – and among providers who practice very differently.
Recently, someone asked why a woman might choose to give birth outside of a hospital, and I replied, “Because I am less afraid of my body than I am of non-evidence-based hospital protocols.”
I truly don’t know if I would choose a home birth, but I do know that the hospital across the street from me has a 40% C-section rate and will call CPS if I decline a routine, non-evidence-based newborn procedure on my baby. I know, from speaking to other mothers, that I “must” give birth by 41 weeks, and if I decline an epidural or medications to speed up labor, I could face ridicule from my caregivers or even a punitive episiotomy if I get unlucky with who is on call.
Knowledge like that complicates these decisions immensely. The question for me isn’t so much, “Is home birth safe?” but, “Is home birth less dangerous than hospital birth?”
The truth is that there’s no such thing as “safe” or risk-free birth in any setting. For each of us, “safety” and “risk” are complicated calculations made within limitations of our individual circumstances and the options at hand. For mothers and families making these important decisions, statistics are helpful, but statistics only illuminate the corners of our own unique sets of certainties and uncertainties.
Polarizing arguments and digging in our heels about these issues don’t make birth safer. Insisting that one location is always safe and one location is never is ridiculous. Pretending that all women are making decisions based on a full set of good options or the same set of health circumstances is unrealistic. Making judgments about someone else’s personal circumstances is nonsensical. We can never know all of the factors that go into those complicated decisions.
Home birth has been around since humans have been, and it doesn’t look like it’s going anywhere.
Hospital birth is where 99% of American birth takes place, and I doubt it’s going anywhere, either.
For real people making real choices, let’s open up the discussion with compassion instead of trying to choke it to death. Transparency and collaboration can make birth safer in all of these settings, but it can’t happen in a hostile environment. If we can let go of our own biases of where women “should” give birth, maybe we can start making birth safer in all of those locations.
* Louisiana is the only state that requires some individual women to seek permission from a state agency (the State Board of Medical Examiners) to hire a midwife for home birth.
Author Cristen Pascucci is Vice President of ImprovingBirth.org and founder of Birth Monopoly, and she'll be in Los Angeles on March 23 to host "Stand On Your Rights L.A.: Demystifying Legal Rights in Childbirth & How to Use Them."